Hospitals vary markedly in the frequency and length of hospitalizations and intensive care unit (ICU) admissions and the number of specialists consulted for chronically ill Medicare beneficiaries during their last 6 months of life. The objective of our proposal is to explore this phenomenon using in-depth hospital case studies. The goal is to identify provider and organizational norms that can be changed in high intensity hospitals to improve efficiency and patient-centeredness of treatment. The specific aims of this R21 are: 1. Identify and describe organizational and provider practice norms that influence the use of LSTs in the ICU for chronically/critically ill elders at one low and one high intensity US hospital. 2. Explore the correlation of these organizational and provider practice norms with provider morale, family satisfaction, quality, and outcomes of care. The research design involves an interviewer and fieldworker engaging in 4 weeks of shadow observation and in-depth analysis of ICU cases based upon semi-structured interviews with the providers, managers, non- clinical staff, and patients or proxy decision makers involved. We will use a mixture of qualitative content analysis of field-notes and interview transcripts, guided by grounded theory, and quantitative analysis of hospital utilization and outcomes data and of provider, patient, and family survey data to develop hypotheses and to draw conclusions about the relationships between norms, intensity, and outcomes. An advisory committee of experts will collaborate with the investigators and hospital staff to develop ideas for a social marketing intervention that could be tested in the future to change norms at the high intensity hospital. The relevance of the proposed project to public health derives from a better understanding of how provider and organizational norms may support or interfere with preferences for decision making and outcomes among critically ill elders. An example of how we would measure success of the project would be the identification of a social norm that encourages advance care planning upon hospital discharge at the low intensity hospital that could be exported using social marketing to the high intensity hospital in order to achieve a reduction in the number of elders with severe limiting chronic illnesses connected to life-support and dying in the ICU. [unreadable] [unreadable] [unreadable]